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By Fanny Alexandra Dietel, PhD, and Ulrike Buhlmann, PhD

I have worried about my appearance for several years. Body dysmorphic disorder (BDD) has ruined my jobs, my relationships, my life.

Still, it took me such a long time to seek help. This scenario — and the long journey of suffering attached to it — is a common experience for those affected by BDD. While frustrating trajectories like these often take a toll on patients, they can also have negative consequences for treatment. As research and clinical experience show, the longer BDD is left untreated, the more adverse repercussions it can have, and the more therapeutic work is usually needed to “pick up the pieces.”

Consequently, addressing barriers to treatment is an important step to improve prognostic perspectives for individuals with BDD. Prior studies in this field paint a rather gloomy picture: only about a third of individuals with the disorder consult mental health treatments, with a majority turning to other options, such as cosmetic surgery. While these low rates are undoubtedly related to logistic and financial barriers, interestingly, treatment utilization patterns are similar in Germany, a country with universal health care and good therapeutic coverage. Thus, despite treatment options being readily available and affordable, the gap between those needing BDD treatment and those getting it might still remain substantial.

From our scientific and clinical experience, we find that this gap is often maintained by certain beliefs and concerns that prevent individuals with BDD from accessing care. This blog post aims to narrow down this gap by providing answers to questions and doubts you might have when considering mental health treatment.

Below, we list common treatment barriers named within treatment and research, along with some encouraging thoughts on how to deal with them.

  1. “If I fix my appearance, everything will be fine.”

This belief is central to BDD and often leads to excessive consultations of cosmetic surgeons, dermatologists, or other providers of cosmetic treatments. Across studies, about a third of individuals with BDD report a preference for medical and cosmetic procedures. Indeed, such cosmetic interventions might result in short-term emotional relief. However, research also shows that BDD symptoms will eventually reoccur or worsen, with concerns shifting to other body parts and triggering further desires to undergo cosmetic procedures. Considering these findings can help you when struggling with recurring thoughts about this issue. Nonetheless, you may also find that urges to change your appearance vary from time to time (e.g., when you are distressed or comparing yourself to others). Even in this case, it is important to acknowledge that psychiatric or psychotherapeutic treatment are still viable options, and it might help to see them as pure ”experiments” first. Your therapist will address feelings of ambivalence about treatment with you, and work on effective coping skills for repetitive thoughts about cosmetic procedures.

2. “BDD is rare and largely unknown. Most healthcare providers would not know how to treat it anyway.”

With rates of about 2% in the general population — or about 6,560,000 people in the US alone — BDD is far from being a rare disorder. In other words, it is likely that other people in your community share your experiences and understand your worries. Online resources like this website can help you learn more about BDD, connect with others and raise awareness for the disorder. Fortunately, within the last decades, effective treatment approaches have been developed, including cognitive behavioral therapy (CBT) and medication. Further, knowledge about BDD has increased substantially among mental health professionals. However, we also know that misdiagnoses might still occur, which is why it is important for patients to be open about their appearance concerns in treatment and ask how the treatment plan addresses BDD specifically.

3. “I am so ashamed. If I talk openly about my appearance concerns, others will…”

People with BDD frequently report fears about being rejected, mocked, stigmatized, or considered vain when disclosing their appearance concerns. These thoughts typically lead to intense feelings of shame, avoidance, social withdrawal, and isolation. It is vital to acknowledge and carefully reverse this tendency. If we put these predictions to the test, we have to consider that reactions to appearance concerns might indeed differ in the general public, especially when people are unfamiliar with BDD. However, most psychiatrists and psychotherapists are aware of the diagnosis today, which makes mental health settings an optimal place to open up about your concerns. In this regard, we cannot stress the importance of talking about BDD enough. Not only will it help you to gradually let go of shame, but it will also direct your health care providers to make effective decisions and tailor treatment to your specific needs and goals.

4. “But I feel that I am ugly — this is the truth. How could psychiatric or psychotherapeutic treatment help me with that?”

This is a very common question. Its assumptions are legitimate since we have all been trained — throughout our lives — to believe in our own thoughts. However, just as in: “Do not believe everything that you read,” we might as well say: “Do not believe everything that you think.” The cognitive behavioral model for BDD states that erroneous, unrealistic thinking patterns produce intense emotions (e.g., anxiety, shame, depression) and increase BDD symptoms (e.g., mirror gazing, excessive grooming). Further, they feed into — and are fed by — perceptual errors, e.g., focusing extensively on parts of your appearance that you dislike. Thus, thinking patterns are an important part of the vicious cycle in BDD, and perpetuate how you see yourself. CBT involves different techniques to break this cycle, such as identifying and challenging unhelpful thinking patterns. In conjunction with other strategies, such as mirror exercises and exposures, changing your thinking and behavior step by step can help you get better. Importantly, innovative developments, such as web- and app-based treatment programs as well as interpretation retrainings, add to the pool of available treatment options.

Finally, we know that breaking new ground can be challenging. With that being said, you can still ask yourself today: “Why is it worthwhile for me to get help for my BDD?” Without giving away too much: there might be very little to lose — and potentially so much to gain.

Fanny Alexandra Dietel, PhD, is a postdoctoral clinical fellow at the University of Muenster, Germany. Ulrike Buhlmann, PhD, is Professor of Clinical Psychology and Psychotherapy and Head of the Outpatient Center at the University of Muenster. Go to bdd.iocdf.org to learn more about BDD, and contact them at info@iocdf.org to get support.

References cited in this article:

Crerand, C. E., Menard, W., & Phillips, K. A. (2010). Surgical and minimally invasive cosmetic procedures among persons with body dysmorphic disorderAnnals of Plastic Surgery65(1), 11.

Dietel, F. A., Zache, C., Bürkner, P. C., Schulte, J., Möbius, M., Bischof, A., … & Buhlmann, U. (2020). Internet‐based interpretation bias modification for body dissatisfaction: A three‐armed randomized controlled trialInternational Journal of Eating Disorders53(6), 972-986.

Enander, J., Andersson, E., Mataix-Cols, D., Lichtenstein, L., Alström, K., Andersson, G., … & Rück, C. (2016). Therapist guided internet based cognitive behavioural therapy for body dysmorphic disorder: single blind randomised controlled trialbmj352.

Schulte, J., Schulz, C., Wilhelm, S., & Buhlmann, U. (2020). Treatment utilization and treatment barriers in individuals with body dysmorphic disorderBMC Psychiatry20(1), 1-11.

Wilhelm, S., Weingarden, H., Greenberg, J. L., McCoy, T. H., Ladis, I., Summers, B. J., … & Harrison, O. (2020). Development and pilot testing of a cognitive-behavioral therapy digital service for body dysmorphic disorderBehavior Therapy51(1), 15-26.

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